Lieutenant Colonel MJ Connolly Royal Army Medical Corps joined the British Army in 1992 as a Combat Medical Technician and commissioned in 1999 as a Medical Support Officer in the Royal Army Medical Corps.

His previous posts include appointments as a Medical Planner at Brigade and Divisional level, Medical Squadron Commander and Second-In-Command of an Armoured Medical Regiment.

He is currently employed as the custodian of Joint Medical Doctrine at the Development Doctrine and Concepts Centre. He has completed several operational tours with NATO including Bosnia, Kosovo, Iraq, Afghanistan and also Angola with the United Nations.

He is qualified in Managing Health and Social Care and is a graduate of the United Kingdom Advance Command and Staff Course where he completed a Master of Arts in Defence Studies with Kings College London. He is a Fellow of the Chartered Management Institute and a Member of the Institute of Healthcare Management.

Lieutenant Colonel Connolly was appointed Deputy Head of the Combat Medical Technician Cadre in 2013.

Lieutenant Colonel Michael Connolly is due to assume command of 1 Armoured Medical Regiment in March 2015.

This article was published at the International Review of the Armed Forces Medical Services Vol 88/2 and presented at the 4th ICMM Pan-Arab Congress on Military Medicine, Dead Sea, Jordan, 4-7 November 2014.

The paper was kindly authorized to be uploaded to my blog by Brigadier MCM Bricknell, Head Medical Operation and Capability, Ministry of Defence, London and by Mr. Ivan Hostens Executive Secretary Adjudant Major at the International Committee of Military Medicine.

INTRODUCTION

Clinical care for combat trauma patients has been transformed over the decade that has seen highly challenging military operations in Iraq and Afghanistan. As a result of this experience, the United Kingdom Defence Medical Services are now widely acknowledged to be amongst the international leaders in this field. Incremental improvements in the system of care have led to a significant number of unexpected survivors compared to the performance of civilian trauma systems. The concepts set out in this paper capture the innovations used to develop this world class system of care through a series of unifying models that articulate the clinical requirements for the United Kingdom military health services support system on operations. This paper illustrates the primary components of the United Kingdom operational patient care pathway and discusses how these models are applied by the Defence Medical Services on operations.

THE CHAIN OF CARE

The chain of care at Figure 1 describes the clinical outcomes required from the operational patient care pathway. The chain of command and the Defence Medical Services collectively contribute to applying health protection measures to the Defence population at risk. If health protection fails, operational patients become sick or injured. First aid measures are essential to save life, limb and eyesight. The chain of command (supported by technical training assistance from the Defence Medical Services) is responsible for training all personnel in essential first aid and a proportion of military personnel in extended first aid.

The Defence Medical Services and the chain of command support the patient in rehabilitation and return to physical, psychological and social function enabling them to return to duty or prepare for discharge from Service on medical grounds. The size of the ovals is indicative of the scale of organizational effort (including but not solely, numbers of personnel involved, proportion of command effort, financial costs, etc.) needed to provide the clinical outcomes at each stage in the chain of care.

THE HEALTHCARE CYCLE

The healthcare cycle at Figure 2 is the patient-centered provision of health service support to the Defence population at risk by the Defence Medical Services throughout their career. The Defence medical operational capability includes those activities carried out by medical force elements in order to provide medical support on operations.

Medical force elements are force generated by the single-Service commands and controlled by the Chief of Joint Operations through the operational chain of command. Surgeon General is the defence authority for the whole healthcare cycle and is responsible for assuring the quality of healthcare delivered to Service and other entitled personnel. The Defence medical operational capability is shaded in purple.

Prior to, and on deployment, the Defence Medical Services support the provision of force health protection measures to service personnel. Service personnel who become operational patients are supported by the ten instruments of military medical care (defined later) and, if necessary, are medically evacuated from the theatre of operations.

Patients are accepted into the National Health Service under the reception arrangements for military patients and are usually admitted to the clinical unit of the Royal Centre for Defence Medicine. Those that require specialists rehabilitation are transferred to the Defence Medical Rehabilitacion Centre. Those patients requiring less specialized rehabilitation will be managed at regional rehabilitation units within the Defence Primary Healthcare organization. Mental health support is provided by Departments of Community Mental Health.

In all cases, after completing their care within the Defence medical operational capability, Service personnel return to the Defence population at risk under the purview of Defence Medical Services firm base medical activities and capability. Administration is undertaken by their own unit, or through Personnel Recovery Units or centres that form the Defence recovery capability. Firm base clinical services are provided on a joint basis through Defence Primary Health Care, Defence Dental Services and Defence Healthcare Commissioning.

THE OPERATIONAL PATIENT CARE PATHWAY

The operational patient care pathway at Figure 3 combines models used in incident management for patients suffering from injuries caused by trauma and chemical, biological and nuclear weapons and links these to the clinical capabilities described in the ten instruments of military medical care. The concept illustrates the continuous, seamless, escalatory increase in clinical care provided to the operational patient. The key to successfully delivering the operational patient care pathway is to continuously and incrementally provide clinical care to meet the needs of the patient, independent of organizational boundaries.

The principles described in the operational patient care pathway also apply to clinical support to the Defence population at risk conducting training and other military activities. It does not, however, encompass extra clinical capabilities that the firm base health services support provide (even if delivered outside the United Kingdom). The operational patient care pathway is applicable to casualties requiring both trauma and acute care. There are two zones of care in the operational patient care pathway.

The hot zone is a non-permissive environment representing an immediate threat to personnel from direct fire or a known environmental threat. Clinical care is limited to care under fire covering only those techniques necessary to provide immediate life-saving interventions while the patient is being extracted. This is likely to be self-administered or buddy-buddy first aid.

The warm zone is a semi-permissive environment representing a specific secondary threat to personnel from indirect fire or other threats. There is not likely to be a demonstrable hard edge to the warm zone. Clinical care is described as tactical field care covering those interventions necessary to save/stabilize life and prepare the patient for medical evacuation. The casualty collection point is likely to be within the warm zone. Conceptually, the clean/dirty line for the handover of casualties from the casualty decontamination area is the edge of the warm zone and the casualty clearing station is outside the warm zone. The area outside the warm zone has explicitly not been labeled. There may be potential threats to the health service support system but these are not sufficiently specific to extend the radius of the warm zone.

Care of the casualty starts at the point of injury in the hot zone. The casualty receives care under fire during extraction from the hot zone which extends to the remainder of the tactical field care capability. Casualties are grouped together at the casualty collection point. After initial triage, casualties are transported to a casualty decontamination area where they are sanitized to remove any threats to their health or that of their careers. If it is not possible to medically evacuate them directly to deployed hospital care, casualties are transported to a critical care station for emergency team care pending medical evacuation to deployed hospital care. Deployed hospital care may be organized in echelons of care, illustrated schematically as forward and rear.

Pre-hospital care (3) encompasses all aspects of health service support forward of deployed hospital care. It includes:

the core functions of primary health care;

pre-hospital emergency care and forward medical evacuation; and

force health protection

Progressive resuscitation is using multiple techniques drawn from technical and organizational advances in clinical care for restoring physiological function for the critically ill or injured patient. Progressive resuscitation incorporates damage control resuscitation for care of the trauma patient.

Damage control resuscitation is the use of hybrid resuscitation techniques including hypertensive resuscitation (the provision of sufficient intravenous fluids to maintain a radial pulse)plus combination blood replacement therapies for trauma.

All aspects are enabled by medical logistics and medical command, control, communication, computers and information, organized as a network, agile, integrated and layered healthcare system. As such, the system is configured to ensure that specific healthcare needs are supported and accessed within accepted timelines. Prolonged care is provided to casualties if there is likely to be a delay in meeting the 10.1.2 (+2) medical planning guideline (4). Moving operational patients between deployed hospital care facilities is referred to as tactical medical evacuation while moving them from the joint operational area to role 4 (5) in the firm base, is called strategic medical evacuation. The Defence Medical Services Inspector General is responsible for Defence Medical Services assurance of the operational patient care pathway under the direction of Surgeon General.

THE MEDICAL PLANNING GUIDELINE

The 10.1.2 (+2) medical planning guideline (6) at Figure 4 is the United Kingdom guideline for the location of clinical capabilities by time in the operational patient care pathway. It is the default for medical operational planning and the operational commander must own the responsibility for any deviations from this guideline. The speed and quality of medical care can reduce the mortality and morbidity of operational patients, The ideal is always to deliver expert care as soon as possible after wounding. Evacuation should be the to the most appropriate facility for the treatment of the casualty, noting that the most appropriate facility may not necessarily be the closest.

All time delays carry clinical risk for patients. It is for commanders, advised by their medical staff, to balance these risks with operational and other factors and to determine whether or not the risks are acceptable. To achieve this in practice, the 10.1.2 (+2) medical planning guideline informs decision making regarding the configuration and location of the medical evacuation and treatment assets needed to provide appropriate medical coverage to the supported force. While primarily expressed as time for the trauma patient, the principles also apply to the non-trauma patient. Evidence from accumulated experience in Iraq, Afghanistan and earlier campaigns, shows that there are three key timelines from point of injury to first surgical intervention and a fourth for in-theatre specialist clinical care (specific terms are defined later under deployed hospital care). The first phase of the medical planning guideline (10.1.2) is cumulative in nature with a limit of 2 hours from point of injury to damage control surgery.

The +2 describes the maximum time for the tactical evacuation of a patient from damage control surgery to in-theatre surgery/enhanced diagnostics within a joint area of operations.

10 minutes-enhanced first aid. Enhanced first aid is those immediate life saving measures that is given to the casualty by personnel trained in enhanced first aid. Bleeding, airway control and administering personal medical countermeasures for the most severely injured patients must be done within 10 minutes of wounding (the so-called platinum ten minutes). For the United Kingdom, this treatment is usually done by the qualified team medic, although personnel from the Defence Medical Services may also be tactically located to support this need.

2 hours-damage control surgery and acute medicine. Patients needing surgery should receive treatment in a facility manned and equipped for damage control surgery (noting the complexity of injuries on operations). Depending on the specific operational circumstances, the aim should be to provide damage control surgery within one hour, but no later than two hours of wounding. Acute medicine is the equivalent clinical capability for non-surgical emergencies. Both damage control surgery and acute medicine should always be supported by a critical care unit. These interventions are designed to stabilize the patient pending further medical evacuation.

+2 hours-in-theatre surgery. Further in-theatre surgery and enhanced diagnostics should be available within two hours of tactical evacuation from damage control surgery/acute medicine for the severely injured and may require deployment of in-theatre specialist capabilities if strategic medical evacuation timelines prevent this guideline being met. (9).

THE TEN INSTRUMENTS OF MILITARY MEDICAL CARE

The ten instruments of military medical care are the essential capabilities required to be considered capabilities to deliver effective health service support on operations. The Defence Medical Services must be able to generate medical force elements against these instruments, mission-tailored to the scale and complexity of a specific operation. The ten instruments of military medical care are described below.

Force health protection. Force health protection is described as the conservation of the fighting potential of a force so that it is healthy , fully combat effective and can be applied at the decisive time and place. It consists of actions taken to counter the debilitating effects of environment, disease and selected special weapon systems through preventive measures for personnel, systems and operational formations. It considers force preparation measures, environmental health advice, in-theatre preventive measures, post-exposure measures and rehabilitating the force. Force health protection must include competent medical advice in force health protection for chemical, biological and nuclear threats. Force health protection incorporates medical intelligence. Medical intelligence is intelligence derived from medical, bioscientific, epidemiological, environmental and other information related to human or animal health.

Pre-hospital emergency care. Pre-hospital emergency care is the system of emergency care provided to a casualty (by individuals or teams) from first clinical intervention at point of injury through to reception of the operational patient at deployed hospital care. The primary clinical output is progressive resuscitation. Pre-hospital emergency care comprises of four clinical phases, one non-clinical node and two clinical nodes of care.

.Tactical field care. Tactical field care covers those interventions needed to save/stabilize life and prepare the casualty for medical evacuation. It can be provided by any extended-trained individual (for example, team medic). Tactic field care incorporates care under fire.

.Care under fire. Care under fire covers those techniques needed to give immediate life-saving interventions to the casualty in the hot zone (10) while the patient is being extracted. Care under fire is the basis of all first aid training taught to our Armed Forces.

.Enhanced field care. Enhanced field care is emergency clinical care usually provided by a clinical team in a more permissive environment using battlefield advanced trauma life support, chemical, biological, radiological and nuclear emergency medical treatment and other progressive clinical techniques.

.Prolonged care. Prolonged care is the application of additional techniques in order to sustain the casualty if any components of the 10.-1.2 ( + 2) medical planning guideline is likely to be exceeded. Delivery of prolonged care will require the medical techniques, skills and capabilities require to hold a patient for a protracted period of time. Prolonged care includes the sub-categories:

.Prolonged pre-hospital care (covering those techniques suitable for use in the pre-hospital emergency care clinical pase), and

.Prolonged hospital care (covering those techniques suitable for use in the deployed hospital care clinical phase).

The application of prolonged pre-hospital care techniques may be adapted to meet a specific tactical situation. The quality of prolonged pre-hospital care provided in non-permissive environments, where there is a threat to security, may require to be compromised. Similarly, improvised methods of prolonged care may be important in semi-permissive environments where conditions are austere. However permissive situations should be used as an opportunity to adopt a controlled response optimizing the standard of prolonged care.

.Casualty decontamination area. The casualty deconta_ mination area is the location where contamination by threats is removed from a casualty to prevent any future threat to the health of the patient or the operational patient care system. This is not a clinical node of care and may be performed by non-medical personnel trained for this role, especially in a chemical, biological, radiological and nuclear threat environment.

.Casualty collection point. The casualty collection point is the first location where operational casualties from an incident are collected after evacuation from the hot zone at which tactical field care is undertaken. It is likely to be in the warm zone and manned by one or more designated Defence Medical Services individuals. In the land environment, the equivalent is a company aid post, while the maritime equivalent it is the first aid post afloat.

.Casualty clearing station. The casualty clearing station is where medical force elements deliver enhanced field care to its patients, usually under the supervision of an independent practitioner. The environment specific force elements are likely to be a unit aid post (Army), medical reception station (Army), sick bay or first aid post (Royal Navy), role 1 (5)(Royal Air Force).

.Primary health care. Primary health care covers those comprehensive community medical services that contribute to the protecting, maintaining and restoring the health of the Defence population at risk. It is often provided by medical forces elements within the casualty clearing station function.

.Deployed hospital care. Deployed hospital care covers those clinical services provided by clinical personnel usually employed within hospitals. Access to deployed hospital care within the 10.1.2 (+ 2)medical planning guideline is an essential component of the operational patient care pathway. Where time/distance precludes providing a single deployed hospital care facility, it may be echeloned into deployed hospital care facilities illustrated as forward and rear facilities though an individual may be treated in more than two deployed hospital care facilities. For example, a patient may initially receive damage control surgery in a role 2 basic medical treatment facility , have general in-theatre surgery in a role 2 enhanced facility and then be transferred to a role 3 facility for sub-specialist care (including ophthalmology or neurosurgery)prior to strategic evacuation. This includes established facilities in the maritime environment.

Deployed hospital care forward facilities are likely to be mobile to provide progressive resuscitation and damage control surgery within two hours. Deployed hospital care rear facilities in the land environment are likely to be static with more mobile assets in the maritime environment. Deployed hospital care will be focused on providing in-theatre surgery and extended diagnostics within two hours of damage control surgery . Deployed hospital care covers damage control surgery and in-theatre surgery, as defined earlier, and the following specific clinical concepts.

.Enhanced diagnostics. Enhanced diagnostics are those clinical support activities (for example a computerized tomography scan if not available as part of damage control surgery, interventional radiology, and specialist laboratory support including biochemistry, haematology and microbiology testing) that enable clinical therapies to address the specific cause of injury or illness that are additional to generic stabilizing therapies.

.Mission-specific clinical capabilities. Mission-specific clinical capabilities are those clinical and clinical support capabilities that are mission-tailored for each specific operation dependent on the threat and medical rules of eligibility. For example, care of captured personnel, emergency care for paediatric patients, tropical medicine, and genitor-urinary medicine.

Medical evacuation. Medical evacuation (11) is moving casualties under medical supervision in a designated transport platform equipped for role. Medical evacuation is controlled by a patient evacuation co-ordination cell that operates under the authority of the battle-space owner to ensure that medical evacuation platforms conform to the tactical environment. The patient evacuation co-ordination cell is responsible for ensuring the right patient is collected from the right pick-up point, transported to the right destination in the right platform, with the right medical escort in the right time. There are three categories of medical evacuation.

.Forward medical evacuation moves patients from point of injury/illness up to deployed hospital care, under medical supervision in a designated transport platform equipped for role (including the critical care station) (12).

.Tactical medical evacuation is moving patients between deployed hospital care facilities within a theatre of operations.

.Strategic medical evacuation is moving patients from the theatre of operations usually to role 4 in the United Kingdom or a first-world standard facility.

Firm base. The firm base includes those capabilities that provide health service support to the Defence population at risk within the strategic base, less the Royal Centre for Defence Medicine and Defence Medical Rehabilitation Centre which are role 4 operational. The firm base plays a vital role in maintaining business as usual including the force generation of personnel to deploy on operations; maintaining force elements at readiness; providing a manning and training margin for commitments and supporting resilience in the United Kingdom.

The medical contribution to security and stabilization. The medical contribution to security and stabilization is where health service support can play a definitive role in delivering operational effect in addition to the operational patient care pathway. These include humanitarian assistance and disaster relief operations, security sector reform and civilian health sector development. Medical force elements may be required to provide capability to support the delivery of effect in all of these areas.

Research and innovation. Research and innovation is used to develop concepts and practical applications that can contribute to sustaining health on operations. This is delivered by Medical Directorate and is supported through the operational healthcare cycle. Perpetual research and innovation enables the delivery of world leading health service support.

HEALTH SERVICES SUPPORT TO THE JOINT OPERATIONAL AREA

Health services support to the joint operational area is designed to be joint and integrated from the outset, providing a continuous , seamless, escalatory increase in clinical care from point of injury/illness until completion of this element of care. Medical force elements are designed to provide environmental self-sufficiency (maritime, land and air)plus effective joint collaboration across components to ensure efficiency in capability and capacity as a joint enabler.

The concept is specifically designated to represent the maximum deployment of health service support to the joint operational area covering the joint, maritime, littoral, land, air assault and air operations. The complexity of medical evacuation within, and between components is shown by the multiple linkages between medical facilities that may well be combined and/or use host nation facilities. Figure 5 summarises the overall concept and illustrates the following specific areas.

. Air component showing a separate air component operating as an expeditionary air wing. This may be part of the major intervention capability or a separate joint expeditionary force lead element operation.

. Strategic role 4. this includes the need for a strategic aeromedical evacuation chain, casualties being received by the Royal Centre for Defence Medicine, and their subsequent care at the Defence Medical Rehabilitation Centre.

Maritime operations. Role 1 support is based on medically trained personnel being assigned to every maritime platform. Role 2 support is provided by medical personnel in platforms specifically equipped and designated with a role 2 afloat facility as a secondary capability. Role 3 support is provided by the primary casualty receiving fitted to Royal Fleet Auxiliary Argus when it is designated as the primary casualty receiving ship. Medical evacuation in the maritime environment is provided by maritime in-transit care teams allocated to assigned platforms (boats or helicopters). Patients will be transferred to shore-based medical facilities(illustrated as host nation)and then strategically evacuated to the United Kingdom. Command of health service support to the maritime component will be embedded within the maritime battle staff.

Littoral operations-the lead commando group. The lead commando group is supported by the commando medical group comprising unit aid posts, dental teams, a commando forward surgical group and a medical reception station. Role 1 support is provided by unit aid posts embedded in combat and combat support forces. The medical squadron of commando logistic regiment provides reinforcing medical support including the commando forward surgical group and a medical reception station. The commando forward surgical group is a role 2 basic capability and has very limited patient holding capability. Littoral operations must be supported by the primary casualty receiving facility afloat, an army field hospital or host nation hospital care.

Command of health service support to the littoral is embedded in 3 Commando Brigade Headquarters but it is likely that additional medical staff will be needed in the maritime component headquarters to manage the entire operational patient care pathway. The medical squadron of Commando Logistic Regiment provides reinforcing medical support including the commando forward surgical group its embedded medical in-transit care team and a medical reception station.

Land Operations-The lead armoured task force(major intervention capability). The lead armoured task force is supported by the lead armoured medical group formed from the affiliated brigade armoured medical regiment and battlegroup unit aid posts. The lead armoured medical group will control organic medical support to combat and combat support battlegroups and provide reinforcing medical support on an area basis to battlespace owners(including combat service support).The medical reception station of the lead armoured medical group will provide general practitioner-led enhanced primary care, peripatetic services and prehospital emergency care stabilization for those patients who have not been moved by air earlier in their medical evacuation. Where required, the pre-hospital emergency care capability and capacity can be enhanced by reinforcing a medical reception station with a ground medical emergency response team.

The Lead Armoured Task Force is also supported by a field hospital. Expansion of health service support if the lead armoured task force expands to a brigade-scale operation, is based upon deploying the remaining elements of the parent armoured medical regiment and expanding the field hospital. Where required,an air manouevre medical group can be grouped with the lead armoured medical group to provide a role 2 basic/deployed hospital care(forward9capability. It may also be necessary to deploty elements of the Reserves, including 335 Medical Evacuation Regiment,306 Hospital Support Regiment and the Operational Headquarters Support Group.

The exact medical command and control structure will depend on the command and control structure for the operation but is likely both the lead armoured medical group and field hospital will be commanded at regimental level with the need for a Commander Medical and supporting staff in either the Joint Task Force Headquarters or the Joint Force Logistic Component Headquarters.

Air assault task force. The air assault task force is supported by the air manoeuvre medical group from 16 Medical Regiment including unit aid posts from combat and combat support battlegroups, The air manouevre medical group includes an air manouvre surgical group. Command and control of health service support to the air assault task force is provided by the 16 Medical Regiment Regimental Headquarters (-)embedded with 16 Air Assault Brigade Headquarters(tactical).The very high readiness field hospital may deploy if the air assault task force operation needs more than one node of deployed hospital care or is likely to endure.

Air operations. Expeditionary air wing. The pre-hospital care squadron provides all the capabilities of operational healthcare(less deployed hospital care)to the expeditionary air wing. Each pre-hospital care squadron is able to support a deployed operating base and an air point of disembarkation, plus provide combat medical support to a RAF Regiment field squadron. There are sufficient pre-hospital care squadrons to support the joint expeditionary force at maximum concurrency. Expeditionary air wings may also be supported by a role 2(air) deployed hospital care medical treatment facility if the medical evacuation timeline to primary surgery is likely to exceed one hour.

Theatre-level health service support. Theatre-level support comprises those medical force elements that support more than one component or contribute to operational rather than tactical effects.

Field hospitals. Field hospitals are force-generated by Army Headquarters but support the whole force. They require significant support from non-medical force elements such as field engineering, communication and information systems, movements and supply. A field hospital will usually be commanded at regimental headquarters level due to the complexity of internal clinical operations. The field hospital may be augmented by clinical personnel in a theatre clinical enhancement team from 306 Hospital Support Regiment to provide specialist clinical care such as ophthalmology , head and neck surgery, neurosurgery, paediatric nursing or midwifery.

Deployed aeromedical evacuation squadrons. A deployed aeromedical evacuation squadron provides theatre-level aeromedical evacuation clinical teams that may be assigned under tactical command as required. There are sufficient deployed aeromedical evacuation squadrons to support the joint expeditionary force at maximum concurrency. It comprises:

. Aeromedical evacuation team. An aeromedical evacuation team provides clinical aeromedical escort for up to five low/minimal dependency patients(dependency levels ¾). This can be augmented by a general medical practitioner , physician, anaesthetist or mental health specialist from elsewhere in the deployed aeromedical evacuation squadron if a patient has specialist clinical needs.

. Critical care air support team. A critical care air support team provides the capability to move critically ill (dependency level ½)through the aeromedical chain. It can escort one critical care air support team patient.

. Aeromedical staging unit. An aeromedical staging unit is a medical unit operating transient patient beds located on, or near emplaning, staging or deplaning air base or air strip. It facilitates reception administration, processing, ground transportation, feeding and appropriate clinical care for patients within the aeromedical staging unit chain. It can hold patients for up to 48 hours.

. Area medical support. Area medical support to the joint logistic support area for a major intervention capability may be provided by a medical squadron from the assigned armoured medical regiment. This is likely to be under tactical control to the battlespace owner but would remain under operational control to the medical group. Personnel from 335 Medical Evacuation Regiment may be deployed to provide clinical personnel for escort of high dependency patients during ground tactical medical evacuation between deployed hospital care facilities.

SUMMARY

This paper provides an insight into the organization and capability of the United Kingdom Defence Medical services. It seeks to aid understanding amongst the international military medical community and develop cooperation. The operational patient care pathway contained in Joint Service Publication 950 provides the unifying concept that underpins the delivery of health service support by the United Kingdom Defence Medical services on operations and should be explored in full in order to develop further knowledge on this system.

ABSTRACT

The ´operational patient care pathway´ 1 is the framework concept established by the United Kingdom Defence Medical Services to illustrate the holistic system of care used to treat the casualties from military operations, The models illustrated in this concept are applied on operations to deliver the world class capability described in the paper ´health service support to the joint operational area´2. This article brings these two concepts together to demonstrate how an overarching theory is applied in practice by the Defence Medical Services on operations. The purpose of this paper is to continue to develop cooperation within the international military medical community by sharing the new military medical concepts developed by the Defence Medical Services in over a decade of operations in Iraq and Afghanistan.

There are currently no definitive planning timelines for the delivery of primary health care.

Enhanced field care is defined later under pre-hospital emergency care.

Progressive resuscitation techniques are taught to all Defence Medical Services personnel. The range of clinical interventions provided is determined by professional qualification and scope of practice.

The United Kingdom Defence Science & Technology Laboratories are examining the specific time upon which to set this threshold. If changed, an amendment to this publication will be published.

The hot zone is a non-permissive environment representing an immediate threat to personnel from direct fire or a known environmental threat.

Medical evacuation must be considered as a tactical activity controlled by the battle space owner at all levels and intimately supported by the function of casualty regulation linked to allied and host nation healthcare networks.

The movement of casualties in a non-designated vehicle without a medical escort is termed casualty evacuation.

Sunday, 8 November 2015

Tao (leadership) is what causes the people to have the same purpose as their superior.Thus they can die with him, live with him and not deceive him.”

– Sun Tzu, 6th Century BC

(The Art of War, Chapter 1 – Appraisals)

On 9 October 2015 a meeting took place at the Health Centre of the Argentine Armed Forces ¨ Malvinas´ War Veterans ¨ which is led by Argentine Army Colonel and 1982 War Veteran Esteban Vilgré La Madrid.

It was a private meeting with a significant audience which gathered together 1982 war veterans of different units and hierarchies in a friendly and professional environment. More than 60 persons attended the event.

That evening Major (Ret.) Mike Seear, former Operations and Training Officer of the 1st Battalion, 7th Duke of Edinburgh´s Own Gurkha Rifles during the 1982 war and also active member of the Nottingham-Malvinas Group, gave a 150-minute lecture on leadership in offensive conventional warfare operations.

Mike Seear was educated at Whitgift School, South Croydon (1959-1966) and the Royal Military Academy Sandhurst (1966-1968).

He works as a Senior Associate for Kenyon International Emergency Services, and had just completed a week-long assignment with Aerolíneas Argentinas in Buenos Aires. Together with his colleague, Kenyon Associate Irma Alcazar, they had presented four emergency response courses to the airline in the period 5-9 October.

His point of contact in Aerolíneas Argentinas was Captain (Ret.) Juan José Membrana, the Safety Instructor in charge of the airline’s emergency response team.

However through an extraordinary piece of fate, Membrana is also a 1982 war veteran and Naval Aviator who performed 11 missions with a Grumman S-2E Tracker aircraft between 28 March and 14 June 1982. Half of those sorties were flown from the aircraft carrier ARA 25 de Mayo, and the remainder from Río Gallegos. He served both as a Commander and Signaller.

Captain (Retd) Juan José Membrana

Grumman S2 Tracker

Amongst the distinguished audience we appreciated very much the honourable English presence in the front row of La Madrid´s mother, 92 year-old Mrs. Meryl Spencer Talbois from Cumbria (UK) whose father was a volunteer during the First World War.

Colonel Esteban Vilgré La Madrid `s mother Mrs Meryl

Spencer Talbois.

After a few introductory words from Colonel La Madrid who referred to a Brotherhood of War, Mike Seear began his presentation which I had the honour of translating into Spanish. Seear displayed and talked about some very interesting images and maps of the 1982 war while de-mystifying some battlefield actions of both sides and extolling the leadership performances of a number of Argentine and British veterans of the war.

Colonel VGM Esteban Vilgré La Madrid and Major (Ret.) Mike Seear. Post-war La Madrid (who in 1982 was an Army Sub-Lieutenant) was subsequently awarded the Medal for Effort and Abnegation. Seven of his platoon were killed on Tumbledown and eight wounded.

Argentine leaders

Apart from Colonel Esteban La Madrid and his courageous actions on Tumbledown with his 3 Platoon of B Company, 6th Infantry Regiment, two Argentine names emerged as leading exponents of leadership during the war of 1982. These were the then Commander (later Rear Admiral) of the Marine Corps 5th Marine Infantry Battalion, Carlos Hugo Robacio who died on 29 May 2011 at the age of 76, and Acting Marine Corps Sub-Lieutenant Manuel Vázquez (later Captain).About Robacio, who was awarded the Argentine Nation’s Medal of Valour in Combat, Seear said: I have calculated that Robacio’s ¨impossible mission¨ was to defend a total frontage of 14 kilometres with his 5th Marine Infantry Battalion. This compares very unfavourably to the average defensive frontage of 2.2 kilometres for British Army Battalions in the Second World War. In other words, the Tumbledown, Mount William and Sapper Hill area should have been defended by a Brigade and not by a Battalion.

Marine Corps Rear Admiral (Retd.)

Carlos Hugo Robacio (General Paz, Corrientes

1933-Bahía Blanca 2011)

Acting Marine Corps Sub-Lieutenant Carlos Daniel Vázquez,

(later Captain (Retd))

Acting Marine Corps Sub-Lieutenant Carlos Daniel Vazquez, commanded 4 Platoon of the 5th Infantry Marine Battalion’s Nacar Company. Located on the west end of Tumbledown, his platoon withstood the attack of the 107 Left Flank Company Guardsmen (one of three rifle companies of the 2nd Battalion, Scots Guards).

Mike Seear said:

Vázquez made a number of decisions to make life much more difficult for the Scots Guards. He deliberately fired all fifty-four remaining mortar bombs of his single 60mm mortar onto his platoon defensive position, reasoning that his men were in cover (in their foxholes). He then repeated this tactic by requesting that the Marines’ 81mm Mortar Platoon fire on his position, and finally that the Argentine artillery fire directly on his position. Vázquez kept his platoon together under the most trying of circumstances. He was isolated (Mino had withdrawn his platoon to the east end of Tumbledown), and one of Vázquez’s section commanders refused to fight. So Vázquez took over command of his section, while simultaneously having to cope with an officer of the 12th Infantry Regiment who was totally traumatised throughout the battle and sat at the bottom of Vázquez’s trench unable to speak. It was Vázquez’s leadership that enabled his platoon to keep together and hold out for nearly seven hours against what was, in effect, the entire Scots Guards Battalion. This was indeed a mini-version of General Custer’s ‘last stand’ at the Battle of Little Big Horn in 1876.

Vázquez was awarded the Medal of Valour in Combat after he had provided proof on Tumbledown of possessing exceptional bravery in combat. He also set an outstanding example to the troops under his command as they remained at their posts while repelling at least three enemy attacks and inflicting heavy casualties on the latter.

Left Flank Company who fought against 4 Platoon had 7 men killed in action and 21 wounded (of whom 18 were hospitalized)

The actions of both men and the characteristics of the battle have been described and analysed in Seear´s latest book Return to Tumbledown: The Falklands-Malvinas War Revisited (2012). This and his first book With the Gurkhas in the Falklands: A War Journal (2003) and second book Hors de Combat: The Falklands-Malvinas Conflict in Retrospect (2009 – with co-editor and 1982 war veteran Diego F. Garcia Quiroga) will be translated soon into Spanish.

Regarding combat techniques Colonel La Madrid said:

The infantryman possesses one characteristic: he obeys simple techniques but requires great creativity, coordination and synchronization. A fighter can be prepared in a short time, but infants with capital letters require something more: "The spirit of the infantryman" that will result in a lethal precision. A leader knows he must get his men to give their lives in fulfilling the mission, and succeeds only through personal example and affection. His men will learn that through hard training. It creates amongst them a sense of "unity" in the true sense of the word which leads them to feel invincible with an heroic contempt for life itself (without being foolhardy), and transforms its members in the closed nucleus of a brotherhood under the word "camaraderie". (Un relato de Malvinas) -

Major John Kiszely, Officer Commanding Left Flank Company, 2nd Battalion, Scots Guards, was awarded the Military Cross for his leadership while attacking the west end of Tumbledown. He led the final bayonet charge up the hill to take Vázquez’s platoon position. It was a wonderful example of ‘I do, you do’ leadership.

Major John Kiszely

Lieutenant Robert Lawrence, 3 Platoon Commander of Right Flank Company, 2nd Battalion, Scots Guards was also awarded the Military Cross for his ‘up front’ leadership during Right Flank Company’s final attack on the east end of Tumbledown. Lawrence was shot in the head towards the end of the battle by a high-velocity 7.62mm round and lost 48 per cent of his brain. But he survived this awful wound and is now married to his second wife.

Lieutenant Robert Lawrence

Lance-Sergeant Clark Mitchell of 15 Platoon, Left Flank Company displayed exceptional courage in engaging the enemy at close quarters during sniping duels on Tumbledown’s west end. He was shot and killed near the end of the battle, and was awarded later a posthumous Mention in Dispatches.

Lance-Sergeant Clark Mitchell with his wife Theresa on their wedding day

Firepower

Mike Seear also described the Royal Navy firepower directed against the defending Argentine forces on Tumbledown and Mount William. The exploding 4.5 inch calibre shells, which were fired at the rate of one every two seconds, left huge craters in the soft peat. But even now, more thirty-three years after the war, it is impossible to convey to those who had not there the unbelievable noise and destructive firepower of these computed-guided automatic guns together with Argentine and British artillery and mortars firing into a concentrated area of eight square kilometres on, and in the vicinity of, Tumbledown and Mount William. It is calculated that more than 16,000 projectiles landed in this particular area during the battle.

There were three Royal Navy ships operating from the northern Berkeley Sound gun line and firing onto Tumbledown. These were:

HMS Yarmouth – a Type 12 frigate armed with 2 x 4.5 inch Mark 6 guns.

HMS Active – a Type 21 frigate armed with 1 x 4.5 inch Mark 8 gun.

HMS Avenger – a Type 21 frigate armed with 1 x 4.5 inch Mark 8 gun.

HMS Yarmouth and HMS Ambuscade – a Type 21 frigate armed with 1 x 4.5 inch Mark 8 gun) were also firing on Wireless Ridge in support of the 2nd Battalion, Parachute Regiment attack on this objective.

Of the eighteen artillery 105 mm Light Guns firing in support of the Scots Guards attack on Tumbledown, one went ´rogue´ early in the battle. The term ´rogue´ is often used for dangerous and crazy elephants. The gun´s fall of shot was unpredictable and threatened to hit the Scots Guards Left Flank Company attacking Vazquez´s 4 Platoon. Indeed this gun probably killed Scots Guardsman Derek Denholm with a direct hit on a boulder under which he was taking cover. Much time was lost in attempting to correct the problem. Later the ´rogue´ gun certainly fired on the 406-strong Gurkha Battalion which had advanced in file along the north-west slopes of Tumbledown before being ‘ambushed’ in an hour-long Argentine artillery and mortar bomb bombardment that caused eight Gurkha casualties.

HMS Yarmouth provides assistance to the Type 21 frigate HMS Ardent which was bombed and sunk by Argentine aircraft during the British amphibious landings at San Carlos on 21 May 1982.

The British 105 mm Light Gun

The attendees

Former Army Captain (now Colonel), Tomas Fox

Former Army Captain (now Colonel), Tomas Fox was a liaison officer in the 4th Artillery Regiment. His mission was to coordinate fire support for his unit. From Mount Harriet, he assisted the 155 mm howitzer located near Sapper Hill in directing its fire against the Gurkhas dug in on Wether Ground between 10 and 12 June 1982. The Battery Commander was Lieutenant Luis Alberto Daffunchio.

Argentine Army- 155mm howitzer

From left to right: Mike Seear, Colonel La Madrid and former Soldier Carlos Alberto Di Santo of A Company, 6th Infantry Regiment.

Mike Seear and war veteran soldier Germán Estrada

Air Defense Artilley (Mar del Plata)

Oscar Teves author of Goose Green who

reconstructed the 12th Regiment´s participation.

Among the attendees was Divisional General (R) VGM Jorge Halperin who, with the rank of Lieutenant-Colonel, fought in the 1982 war as the Commanding Officer of the 6th Infantry Mechanised Regiment General Viamonte and Marine Corps Captain (Ret.) Waldemar Aquino of the 5th Marine Infantry Battalion who also fought in the war. Aquino was awarded the Medal of Honour for Valour in Combat of the Argentine Navy, Medal of the Argentine Nation for Valour in Combat awarded by the Executive Powers, Steel Medal of the Honourable Congress of the Argentine Nation and the Medal of the Province of Tierra del Fuego.

Take the initiative (by using the unconventional) to maintain the momentum of the attack.

If the enemy is within range, so are your men.

Ammunition is cheap, your men´s lives aren´t.

Advantage of weight of fire vs. disadvantage of the weapon system´s weight for your men is a commander´s eternal dilemma.

Remember even near the battle´s end that incoming fire always has the right of way.

Friendly fire isn´t: but it´s always part of battle.

Never underestimate Murphy´s Law.

¨Therefore, 100 victories in 100 battles is not the most skilful. Subduing the other´s military without battle is the most skilful¨

Final toast

Silvia Barrera

At the end of the barbecue, war veteran Silvia Barrera offered a chocolate cake to Mike before the toast. Barrera was one of the Army´s civilian surgical scrub nurse who served aboard icebreaker ARA Almirante Irizar (Q-5) (RHAI).